Ectopic clival craniopharyngioma

Ectopic craniopharyngioma of the orbit: illustrative case

BACKGROUND

Craniopharyngiomas are uncommon malformations of the sellar or parasellar region that are partly cystic and calcified and have low histological grade. The typical age of presentation is bimodal, with peak incidence rates in children at age 5 to 14 years and in adults at age 50 to 74 years. The usual clinical manifestations are related to endocrine deficiencies due to mass effect along with visual impairment and increased intracranial pressure. If a tumor is favorably localized, the treatment of choice is complete resection.

OBSERVATIONS

The authors presented a unique case of a 61-year-old man with a suspicious cystic lesion in the right orbital roof that was causing right-sided headaches with pressure and pain in the right eye. Both computed tomography and magnetic resonance imaging were used for further evaluation and showed a suspicious lytic bone lesion that had an epicenter within the orbital rim, which was highly suggestive of a tumor of interosseous origin. After removal, the tumor was identified by pathology as a craniopharyngioma.

LESSONS

The importance of this case report is in documenting a unique case of an ectopic craniopharyngioma in the orbit, adding to current hypotheses of the pathogenesis of ectopic craniopharyngiomas, and presenting an extensive review of literature.

The association of ectopic craniopharyngioma in the fourth ventricle with familial adenomatous polyposis: illustrative case

BACKGROUND

Craniopharyngioma (CP) often arises in the sellar and suprasellar areas; ectopic CP in the posterior fossa is rare. Familial adenomatous polyposis (FAP) is a genetic disorder involving the formation of numerous adenomatous polyps in the gastrointestinal tract, and it is associated with other extraintestinal manifestations.

OBSERVATIONS

The authors reported the case of a 63-year-old woman with FAP who presented with headache and harbored a growing mass in the fourth ventricle. Magnetic resonance imaging (MRI) findings revealed a well-circumscribed mass with high intensity on T1-weighted images and low intensity on T2-weighted images and exhibited no contrast enhancement. Gross total resection was performed and histopathology revealed an adamantinomatous CP (aCP). The authors also reviewed the previous reports of ectopic CP in the posterior fossa and found a high percentage of FAP cases among the ectopic CP group, thus suggesting a possible association between the two diseases.

LESSONS

An ectopic CP may be reasonably included in the differential diagnosis in patients with FAP who present with well-circumscribed tumors in the posterior fossa.

Primary ectopic parasellar craniopharyngioma: a case report

BACKGROUND

Craniopharyngioma (CP) is a slow-growing, benign tumor of the central nervous system located within the sellar and suprasellar regions. The tumor may extend from the suprasellar region to other areas. CPs are generally believed to originate from squamous remnants of an incompletely involuted craniopharyngeal duct that also develops from Rathke's pouch. Primary parasellar craniopharyngioma is a relatively rare tumor, and nasal endoscopy, computed tomography, and enhanced magnetic resonance imaging can be applied to better evaluate the invasiveness and characteristics of these tumors.

CASE PRESENTATION

We report a case of right parasellar craniopharyngioma in a 49-year-old female patient with a 10-day history of dizziness and blurred vision. Preoperative imaging examination revealed right parasellar space-occupying lesions, and the patient underwent transnasal neuroendoscopic resection of the right parasellar space-occupying lesion. The postoperative pathological result confirmed craniopharyngioma.

CONCLUSIONS

Primary ectopic parasellar craniopharyngioma is a relatively rare tumor, and preoperative imaging examination can assist in the evaluation of tumor characteristics. However, the final diagnosis continues to depend on the histopathological results.

Ectopic GH-secreting pituitary adenoma of the clivus: systematic literature review of a challenging tumour

PURPOSE

Acromegaly is usually due to growth hormone (GH)-secreting pituitary adenomas, but it may be exceptionally caused by GH-secreting ectopic pituitary adenomas (EPA). EPA are defined as extra-sellar pituitary tumours, extra- or intra-cranially sited, entirely separated from the pituitary stalk and gland. The aim of the study is to address the challenges in the management of clival GHEPA.

METHODS

We reported a case of a 53-year-old acromegalic patient with a primary clival GHEPA and reviewed systematically the relevant English literature between 1975 and 2019, in keeping with the PRISMA guidelines.

RESULTS

Four cases of primary clival GHEPA have been described in literature apart from ours. All patients presented with acromegalic features, elevated circulating GH and/or insulin-like growth factor-1 levels. Hyperprolactinemia and empty sella were described in two cases, respectively. These tumours show the typical imaging characteristics of pituitary adenomas, but their neuroradiological diagnosis may be challenging due to their sizes and the difficulty in defining the absence of connections with the pituitary fossa.

CONCLUSION

Although primary clival GHEPA are exceedingly rare, even if likely under-reported in literature, they should be considered in the differential diagnosis of clival tumours because of their specific management. Surgery represents the first-line treatment option, while medical and radiation therapies can be adopted as neo-adjuvant, adjuvant or primary treatments according to tumour and patient characteristics.

Ectopic clival craniopharyngioma with intratumoral hemorrhage: A case report

Craniopharyngiomas located outside the intra/suprasellar region are rare and the incidence of intratumoral hemorrhage is also rare. A 45-year-old woman with visual field defect underwent subtotal resection of the tumor located in the skull base. CT revealed a well-defined mass with calcifications involving the clivus, and MRI showed anterior displacement of a normal pituitary gland by the mass consisting cystic portions with some fluid-fluid levels and enhancing solid portions. Surgery and histopathological examination revealed an ectopic adamantinomatous craniopharyngioma arising from the clivus with intratumoral hemorrhage. Though this condition is rare, detailed analysis of symptoms in association with imaging findings should alert the physician to the possibility of craniopharyngiomas.

Ventriculoscopic Surgery for Cystic Retrochiasmatic Craniopharyngiomas: Indications, Surgical Technique, and Short-Term Patient Outcomes

BACKGROUND

Attempted gross-total resection for the management of cystic retrochiasmatic craniopharyngiomas can cause severe hypothalamic dysfunction and decrease overall survival. Ventriculoscopic surgery is a minimally invasive alternative; however, potential indications and technique have not been well defined.

OBJECTIVE

To present our indications and technique for the ventriculoscopic treatment of cystic retrochiasmatic craniopharyngiomas.

METHODS

We evaluated all patients with retrochiasmatic craniopharyngiomas for ventriculoscopic surgery. Indications and operative technique were developed to minimize operative morbidity, relieve mass effect, and optimize functional outcome. Cyst size and functional outcomes were statistically evaluated to determine radiographic and short-term clinical outcome.

RESULTS

Indications for ventriculoscopic surgery included (1) radiographic evidence of hypothalamic involvement and (2) major cystic component. Ten patients met indications, and mean follow-up was 2.5 ± 1.6 yr. The surgical technique included wide cyst fenestration at the foramen of Monro, and fenestration of inferior cyst wall/third ventriculostomy ("through-and-through" technique). Preoperative Karnofsky performance status was 70 ± 15 and was inversely correlated with preoperative cyst size (13 ± 13 cm3). A statistically significant reduction in cyst size was found on early postoperative imaging (2.1 ± 4.3 cm3). Seven patients received postoperative radiotherapy. Postoperative performance scores (81 ± 8.3) had improved; no patient suffered functional decline. Pre- and postoperative body mass indices were similar. No patient had short-term hypothalamic obesity.

CONCLUSION

Ventriculoscopic surgery, with or without adjuvant treatments, can reduce early postoperative tumor volume and improve short-term functional status in cystic retrochiasmatic craniopharyngiomas with hypothalamic involvement; it should be considered a minimally invasive option in the multimodal treatment of craniopharyngiomas. Further studies are needed to determine long-term efficacy.

Endoscopic transnasal surgery of clival lesions: our experience

BACKGROUND

The clivus is a region characterized by complex anatomy, with vascular and neural structures that are located in close proximity. Different pathologies can affect this area, and traditional surgical approaches were open approaches. Recently, the endoscopic transnasal technique has been introduced, and currently represents a good alternative for the surgical management of these lesions. This is a preliminary report on patients treated endoscopically for clival lesions by the authors' Skull Base Team.

PATIENTS AND METHODS

This was a retrospective chart review of patients who underwent an endoscopic exclusive transnasal approach (EEA) or a transoral one (TO) for clival lesions between June 2015 and November 2017 at our Skull Base Referral Center. Patient characteristics and symptoms, preoperative neuroradiological evaluation, surgical approach, complications, and postoperative results were evaluated.

RESULTS

Nine patients (6 females and 3 males; age range 6-82 years, mean 50.8 years) underwent EEA or TO. From histological analysis, we found chordomas (6/9 subjects), chondrosarcoma (1/9), craniopharyngioma (1/9), and eosinophilic granuloma (1/9). Three patients had previously been operated for a parasellar chondrosarcoma (1/9), a pituitary macroadenoma (1/9), or a chondroid chordoma (1/9). The lesions were totally (2/9) or sub-totally (5/9) resected, debulked (1/9), or analyzed with a biopsy (1/9). Reconstruction was accomplished with a multilayer technique (7/9), or with a gasket-seal (1/9), using a mucoperichondrial graft, a single/double nasoseptal flap, a middle turbinate flap, a fascia lata, or a synthetic fascia. One patient (11.1%) was re-operated on due to cerebrospinal leakage, without further complications. Two patients (22.2%) were re-operated on due to chordoma regrowth. Adjuvant chemotherapy was administered to 1/9 patient with progressive healing. All of the other patients underwent proton-beam radiotherapy with no documented tumor growth (median follow-up: 20 months; range 5.1-29.9 months).

CONCLUSIONS

Clival lesions represent a heterogeneous group of lesions located in a very complex and difficult area. EEA and TO approaches are safe and mini-invasive, with lower morbidity and with postoperative complications when compared to the traditional open approaches, according to the extent and type of pathology.

Unusual and Rare Locations for Craniopharyngiomas: Clinical Significance and Review of the Literature

OBJECTIVE

This study discusses rare and unusual locations of primary craniopharyngiomas.

METHODS

We describe a case of a craniopharyngioma in the cerebellopontine angle. As a result of this unusual location, we performed a literature review of the ectopic occurrence of craniopharyngiomas using Pubmed, Cochrane Database, Trip, and Google Scholar to search for the terms "unusual," "uncommon," and "ectopic" in combination with "craniopharyngioma." The bibliographies of relevant articles were also searched.

RESULTS

We found 28 reported cases of rare anatomic locations for primary craniopharyngiomas. The average age of the patients was 30.8 years. Several patients had Gardner syndrome.

CONCLUSIONS

Craniopharyngiomas are most often located in the suprasellar region. Presentation in sites outside the parasellar region is rare. Among these ectopic sites, the cerebellopontine angle appears to be the most common location.

Primary ectopic frontotemporal extradural craniopharyngioma

We present a case of primary ectopic frontotemporal extradural craniopharyngioma. Primary ectopic craniopharyngiomas are very rare and have been reported involving the fourth ventricle, infrasellar region, lateral ventricle, temporal area, cerebellopontine angle, clivus, corpus callosum, and prepontine cistern. There was just 1 case of craniopharyngioma previously presented in the literature, with nearly same location as the presenting case.

Ectopic craniopharyngioma of the fourth ventricle in a patient with Gardner syndrome

Ectopic craniopharyngioma is uncommon and a craniopharyngioma confined purely within the fourth ventricle is extremely rare. We report a craniopharyngioma of the fourth ventricle in a 20-year-old man with Gardner syndrome. Imaging characteristics of craniopharyngiomas and fourth ventricle lesions are discussed with a review of the literature regarding the pathogenesis of craniopharyngiomas and the possible association with Gardner syndrome.

Isolated petrous apex ectopic craniopharyngioma

Primary ectopic craniopharyngioma is a rare entity. Isolated petrous apex bone location has not been reported previously. This study reports a case of 26-year-old male with right abducent nerve palsy. CT and MRI imaging reveal right petrous apex cystic lesion. No sellar or suprasellar region involvement was found. Endoscopic endonasal transphenoid approach has been successfully performed. Histopathology examination confirms the diagnosis of adamantinomatous craniopharyngioma. So far, it’s probably the first case report of primary ectopic craniopharyngioma isolated in the petrous apex. This case report supports the premise that primary ectopic craniopharyngioma is a multifactorial process that starts with an error from migrated embryological cells.

Clival pituitary adenoma with acromegaly: case report and review of literature

The pituitary develops as a result of complex, intricate, and precise neuro-embryological events in the sixth to eighth weeks of gestation. Some ectopic cell rests can become adenomatous. Rarely, these cell rests in the clivus can be the site of formation of adenoma. Our patient, a 35-year-old parous woman, was being treated for acromegaly, and imaging studies revealed a clival mass lesion. Trans-sphenoidal excision was done and immunohistochemistry revealed the tumor to be a growth hormone-secreting tumor.

Pituitary stalk craniopharyngioma

Craniopharyngiomas are benign but aggressive neoplasms arising along the craniopharyngeal duct. It is frequently located in the suprasellar region. Primarily pituitary stalk craniopharyngioma is unusual and uncommonly early diagnosed, before it enlarges and extends to supra or parasselar region. This unusual location and the small size pose therapeutic dilemmas, since it has the ability to grow larger. Currently, no consensus exists regarding the optimal management. The authors have recommended complete resection.

Optimal treatment strategy for craniopharyngiomas based on long-term functional outcomes of recent and past treatment modalities

Although many authors have described treatment strategies for craniopharyngiomas, the optimal treatment of craniopharyngiomas remains controversial. This study aimed to define an adequate surgical strategy for craniopharyngiomas by reviewing the long-term functional performance of patients treated by current and past treatment modalities. Fifty-five patients with longer than 5 years of follow-up were selected for the present long-term study. The duration of follow-up ranged from 5.5 to 33 years (median, 14.8 years). There were 28 adult patients (14 males; median age, 44.4 years) and 27 children younger than 16 years of age (15 males; median age, 8.1 years). The patients were divided into the following treatment groups: single surgery (group A; n=14 multiple surgeries (group B; n=8), surgery or surgeries followed by radiotherapy (group C; n=23), surgery or surgeries (partial removal) followed by radiotherapy + additional treatments (multiple surgeries and/or re-irradiation; group D; n=10). In addition to the routine assessments of neurological, endocrine, and visual outcomes, the level of daily functioning was analyzed using the Karnofsky Performance Scale (KPS). Statistical analysis of relationship between KPS score and treatment mode demonstrated that group D had a significantly lower KPS score (F=5.82, p=0.0017). Furthermore, mortality, cognitive function, and visual function were significantly better in groups A, B, and C than in group D. Multiple regression analysis demonstrated that cognitive dysfunction, visual disturbance, and treatment mode were independent covariates that significantly affected postoperative KPS score. Adequate primary treatment for craniopharyngiomas is important to avoid subsequent multiple treatments. Craniopharyngiomas should be removed surgically as far as possible but without further deteriorating cognitive and visual functions, either as total resection or subtotal resection with a small remnant that is controllable by radiation therapy.

Metastatic craniopharyngioma: case report and literature review

BACKGROUND

Distant spread of craniopharyngioma is a rare but important complication. Most cases are a result of spread along the surgical path. We describe a rare case of metastatic leptomeningeal craniopharyngioma as a result of dissemination along CSF pathways in a child. A review of previously described cases is provided.

CASE PRESENTATION

A 14-year-old male was diagnosed with metastatic craniopharyngioma on routine follow-up imaging after multiple surgeries and radiation for locally recurrent craniopharyngioma. The lesion was erosive through the right parietal bone, but had remained clinically silent. The lesion was distant from previous surgical paths. The patient underwent right parietal craniotomy and resection of the lesion. Duraplasty and cranioplasty were necessary for closure. Histopathology confirmed adamantinomatous craniopharyngioma. One-year follow-up demonstrated no recurrence.

DISCUSSION

A review of reported cases suggests that leptomeningeal implantation may be an important step in metastases of craniopharyngioma, although the mechanism is poorly understood. Attention to tumor spillage at the time of surgery may be important in preventing distant recurrences.

Endoscopic trans-sphenoidal surgery for pituitary tumors

Trans-sphenoidal surgery, which is the most widely used technique for the treatment of pituitary tumors, has continued to evolve by introducing new approaches and technologies, such as the direct endonasal route and the endoscope. The endonasal approach is a minimally invasive route to the sella turcica with the advantages of using a simpler and more rapid nasal dissection and eliminating the nasal and lip complications. Restricted exposure provided by the endonasal approach is overcome by combined use of an endoscope that provides a more panoramic view of the surgical field beyond the area covered by the operating microscope. An operating microscope permits binocular vision and bimanual technique, which are familiar to neurosurgeons. Neurosurgeons should exploit the advantages of both modalities for the benefit of patients. This review describes the advances in trans-sphenoidal surgery focusing on the endoscopic approach.

Temporal extradural ectopic craniopharyngioma

✓A rare case of histologically confirmed primary craniopharyngioma at an ectopic location is presented. This cystic tumor, which had a small solid portion, was located extradurally at the right temporobasal region, and pyramidal bone erosion was observed. No evidence of involvement of the sellar or suprasellar region was found. The neuroimaging findings, surgical intervention, and histopathological features of the tumor are discussed. The authors' hypothesis regarding the extradural location of the tumor is that mismigration of squamous epithelial cell remnants of the obliterated craniopharyngeal canal had occurred.

The Spectrum of Malignancy in Craniopharyngioma

Craniopharyngiomas are low-grade epithelial neoplasms occurring almost exclusively in the sellar/suprasellar region. Histologic malignancy is extremely rare; the literature consists mostly of isolated case reports. Herein, we report 3 patients with craniopharyngiomas exhibiting histologic malignancy, 2 of which received radiation therapy before its appearance. Hematoxylin and eosin-stained slides and selected immunohistochemical stains were reviewed in all cases. Microvessel density analysis was performed in case 2. The patients included 2 men and 1 woman, age 14, 31, and 58 years at presentation, respectively. All patients expired 3 months to 9 years after first resection and 3 to 9 months after identification of histologic malignancy. The latter developed after multiple recurrences and radiation therapy in 2 cases, but seemed to arise de novo in 1 case resembling odontogenic ghost cell carcinoma and lacking any definite low-grade craniopharyngioma precursor. The malignant component of the other 2 cases resembled squamous cell carcinoma and low-grade myoepithelial carcinoma, respectively. The MIB-1 labeling index was markedly increased in the malignant component in comparison with the low-grade precursor. Malignant transformation in craniopharyngiomas, although rare, does exist. It assumes varied histologic appearances, usually after multiple recurrences and radiation therapy, and has a near uniformly fatal outcome. De novo malignancy in odontogenic tumors of the sella is even more unusual, but also has an ominous prognosis.

Recurrent infrasellar clival craniopharyngioma

The patient is a 44-year-old man who underwent resection of a posterior nasopharynx tumor 12 years earlier via left lateral rhinotomy approach. The final pathological analysis indicated the tumor was a craniopharyngioma, and the patient subsequently underwent focal radiation. The patient returned to medical attention complaining of dysequilibrium. A neurologic exam was nonfocal. Magnetic resonance imaging revealed a clival mass, separate from the sella turcica, with imaging characteristics concerning for chordoma or primary bone tumor (Fig. 1). The lesion was resected via an endoscope-assisted endonasal transsphenoidal approach, with gross total resection achieved. Intraoperatively, the mass was noted to erode through the posterior nasopharynx, without extension superiorly into the sella or posteriorly through the clival dura (i.e., lesion was infrasellar). The final pathological results indicated the tumor was adamantinomatous craniopharyngioma.

Cerebellopontine angle craniopharyngioma: case report and literature review

The authors report an unusual case of adamantinomatous craniopharyngioma occurring in isolation in the cerebellopontine angle of a 12-year-old female. The patient presented with a 1-year history of nausea, vomiting, and headache. MRI revealed a left cerebellopontine angle tumor without connection to the suprasellar space. Following near-total resection, histological review confirmed the lesion as an adamantinomatous craniopharyngioma. This is only the third published report of craniopharyngioma occurring in isolation in the cerebellopontine angle. The case report and a brief review of the literature are presented.